eMedicine Specialties > Infectious Diseases > Gastrointestinal Tract and Intra-abdominal Infections
Salmonellosis: Treatment & Medication
Updated: Mar 31, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Salmonella gastroenteritis is usually a self-limiting disease. Fluid and electrolyte replacement may be indicated in severe cases. Because antibiotics do not appear to shorten the duration of symptoms and may actually prolong the duration of convalescent carriage, they are not routinely used to treat uncomplicated nontyphoidal Salmonella gastroenteritis. Current recommendations are that antibiotics be reserved for patients with severe disease or patients who are at a high risk for invasive disease .
- Historically, recommended regimens for the treatment of typhoid fever included ampicillin, trimethoprim-sulfamethoxazole, or chloramphenicol. Emerging drug resistance over the past 20 years has limited the usefulness of these antibiotics. Presently, quinolone, macrolide, and third-generation cephalosporin antibiotics are preferred for empiric therapy pending sensitivities. Unfortunately, sensitivity to quinolones has been steadily declining, and these are no longer fool-proof agents for typhoid fever.
- Clinical data suggested reduced effectiveness of quinolone therapy in patients with nalidixic acid-resistant Salmonella strains.33 A study of more than 1000 stored Salmonella isolates from Finland has confirmed earlier data that showed that resistance to nalidixic acid by means of disk diffusion is a sensitive and specific method of screening Salmonella isolates for reduced susceptibility to fluoroquinolones.34
- Although uncommon in the United States, resistance to quinolone antibiotics among typhoidal and nontyphoidal salmonellae is increasingly common elsewhere. In one 22-year surveillance study in Spain, the prevalence of nalidixic acid resistance increased almost 80-fold to 38.5%.
- In a recent review of US data from the National Antimicrobial Resistance Monitoring System, 58% of S typhimurium isolates isolated between 1997 and 1998 were resistant to at least one antibiotic, and 3 multidrug-resistant strains (resistant to ≥5 antibiotics) accounted for 74% of isolates.
- Salmonella bacteremia is generally treated with a single bactericidal drug for 10-14 days. Given the resistance trends, life-threatening infections should be treated with both a third-generation cephalosporin and a fluoroquinolone until the susceptibilities of antimicrobial agents are known.2
- If endocarditis or infectious arteritis is documented, urgent surgical treatment is usually necessary. Antimicrobial therapy for endovascular infections should be continued for a minimum of 6 weeks after successful surgery.
- Years of therapy might be needed when surgery is not possible (eg, retained prosthetic devices, chronic bone and joint infections).2
- For proven or possible CNS involvement, high-dose ceftriaxone would be the best choice for optimal penetration of the blood-brain barrier.2
Surgical Care
Typhoid fever is occasionally complicated by intestinal perforation or hemorrhage, cholecystitis, endocarditis, arteritis, osteomyelitis, or soft-tissue abscess formation, necessitating surgical intervention.
- Long-term S typhi carriage (usually with the gallbladder as the reservoir) may necessitate cholecystectomy.
- Splenectomy may be required for splenic abscesses.2
- Surgical care dramatically improves the likelihood of survival in patients with endarteritis, especially that which involves abdominal aorta. A review of 148 cases from 1948-1999 found a 62% survival rate in all patients treated with combined surgical and medical therapy and a 77% survival rate in 30 patients who were able to undergo extra-abdominal bypass with construction of an axillobifemoral graft.35,36
Consultations
Consultation with an infectious disease specialist should sought in cases of bacteremia, endovascular infections, CNS infections, and whenever typhoid fever is a strong possibility, as well as when antimicrobial resistance is suspected or documented.
Medication
The goals or pharmacotherapy are to eradicate infection, to reduce morbidity, and to prevent complications.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ciprofloxacin (Cipro)
Fluoroquinolone with good activity against Salmonella and most aerobic gram-negative organisms, although resistance is gradually increasing. Poor activity against anaerobes and most gram-positive organisms. Inhibits bacterial DNA topoisomerases.
Adult
Gastrointestinal nontyphoidal salmonellosis requiring therapy: 500 mg PO bid for 3-7 d
Severe nontyphoidal salmonellosis, focal infection, or infection in patients with AIDS: 400 IV bid, changing to 500-750 PO bid for 1-6 wk
Typhoid fever: 400 mg IV bid (switch to PO when tolerated) for a total course of 7-10 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, dairy products, sucralfate, iron salts, and zinc salts may reduce serum levels; administer 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, mexiletine, caffeine, methotrexate, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of oral anticoagulants (monitor PT/INR)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in patients with renal impairment; superinfections may occur with prolonged or repeated antibiotic therapy; Clostridium difficile colitis may occur, rarely causes crystalluria (avoid alkalinization; patients should be well hydrated); may cause adverse CNS effects (eg, anxiety, insomnia, nervousness, agitation, nightmares, paranoia); may cause sunburnlike photosensitivity (avoid excessive sunlight); Achilles tendinopathy occurs rarely
Azithromycin (Zithromax)
A macrolide antibiotic with enhanced gram-negative activity and a long half-life
Adult
Typhoid fever: 1000 mg PO qd for 5 d
Severe nontyphoidal gastroenteritis: 1000 mg on day one, then 500 mg PO for 6 d
Pediatric
20 mg/kg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; infrequently increases hepatic enzymes; caution in patients with impaired hepatic function, prolonged QT intervals, or advanced age
Ceftriaxone (Rocephin)
Arrests bacterial growth by binding to one or more penicillin-binding proteins. A third-generation cephalosporin with broad-spectrum activity, although not a preferred anti-staphylococcal agent. Its gram-negative activity is limited against many multiresistant nosocomial organisms.
Adult
Typhoid fever: 2-3 g IV qd for 7-14 d
Pediatric
50-75 mg/kg IV q12h
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity; may enhance warfarin effect; calcium supplements may reduce effectiveness of drug
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in women who are breastfeeding; not to be administered to preterm or neonates; may cause pseudocholelithiasis
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antimicrobial activity of TMP-SMZ is broad and includes MRSA, most common UTI and diarrheal pathogens, toxoplasmosis, Isospora species, and Nocardia species, among many others.
Adult
Salmonella gastroenteritis: 160 mg TMP/800 mg SMZ I DS tab PO bid for 3-7 d (check sensitivities)
Pediatric
<2 months: Do not administer
>2 months: 8 mg/kg/d TMP and 40mg/kg/d SMZ PO bid
Often increases PT when used with warfarin (must perform coagulation tests and adjust dose accordingly); coadministration with dapsone or digoxin may increase blood levels; coadministration with diuretics may cause electrolyte abnormalities (monitor); phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine; may cause nephrotoxicity when coadministered with cyclosporine; indomethacin may increase serum sulfamethoxazole levels; may cause megaloblastic anemia in patients concurrently receiving pyrimethamine; may decrease efficacy of TCAs
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Minor rash is common (discontinue if worsening skin rash or any mucosal involvement); obtain CBCs and LFTs for prolonged or high-dose therapy; discontinue or modify therapy if significant hematologic or hepatic changes occur; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in patients with folate deficiency (eg, chronic alcoholism, advanced age, anticonvulsant therapy, malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS have more rash and toxicity; caution in patients with renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Chloramphenicol (Chloromycetin)
Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. PO formulation unavailable in the United States.
Adult
Typhoid fever: 500 mg PO/IV qid for 14 d
Pediatric
75-100 mg/kg/d
Concurrently with barbiturates, chloramphenicol serum levels decrease while barbiturate levels increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin and rifabutin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum phenytoin levels, possibly resulting in toxicity
Documented hypersensitivity; bone marrow depression; impaired hepatic function
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use limited owing to risk of serious and sometimes fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia); evaluate baseline and perform periodic blood studies approximately every 3 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or dose-related adverse effects; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome); not recommended in women who are breastfeeding; serum concentrations must be performed in pediatric patients with impaired or immature metabolic functions or in patients who are receiving medications also metabolized by the liver
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| Overview: Salmonellosis |
| Differential Diagnoses & Workup: Salmonellosis |
 Treatment & Medication: Salmonellosis |
| Follow-up: Salmonellosis |
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Further Reading
Keywords
salmonellosis, Salmonella infection, salmonellae, Enterobacteriaceae, enteric fever, typhoid fever, Salmonella bacteremia, Salmonella osteomyelitis, Salmonella gastroenteritis, nontyphoid Salmonella infection, nontyphoidal Salmonella infection, Salmonella choleraesuis, Salmonella typhi, Salmonella paratyphi, Salmonella typhimurium, Salmonella enteritidis, Salmonella heidelberg, S choleraesuis, S typhi, S paratyphi, S typhimurium, S enteritidis, S heidelberg, Salmonella enterica, S enterica, Salmonella enteritidis heidelberg, S enteritidis heidelberg, Salmonella enteritidis newport, S enteritidis newport, Salmonella hadar, S hadar, Salmonella enteritidis agona, S enteritidis agona, Salmonella enteritidis montevideo, S enteritidis montevideo, Salmonella oranienburg, S oranienburg, Salmonella muenchen, S muenchen, Salmonella enteritidis thompson, S enteritidis thompson
